British anti-Lewisite

Ravindra Kumar Garg MD (Dr. Garg of King George's Medical University in Lucknow, India, has no relevant financial relationships to disclose.)
Matthew Lorincz MD PhD, editor. (Dr. Lorincz of the University of Michigan receives salary support from Wilson Therapeutics AB for performing UWDRS examinations in a clinical trial.)
Originally released November 30, 2006; last updated August 9, 2016; expires August 9, 2019

Overview

British anti-Lewisite was developed in 1941 as an antidote to lewisite, an arsenic-based chemical warfare agent. British anti-Lewisite is used in arsenic, gold, and mercury (soluble inorganic compounds) poisoning. This drug is not indicated in patients with iron, cadmium, selenium, silver, or uranium poisoning. British anti-Lewisite is occasionally used for both acute heavy metal intoxication and Wilson disease. Parenteral British anti-Lewisite can be successfully used in lead poisoning if oral therapy fails.

Key points

 

• British anti-Lewisite is a chelating agent.

 

• British anti-Lewisite has a greater affinity for metal than for body proteins, and thus reverses the functioning of these proteins.

 

• British anti-Lewisite is used in arsenic, gold, and mercury (soluble inorganic compounds) poisoning.

 

• British anti-Lewisite is not indicated in iron, cadmium, selenium, silver, or uranium poisoning.

 

• British anti-Lewisite is administered by deep intramuscular injections of 2 to 5 mg/kg, 1 to 4 times per day for up to 10 days.

 

• It is no longer the preferred chelating agent.

Historical note and terminology

Lewisite (2-chlorovinyldichoroarsine) is an arsenic-based vesicant chemical warfare agent that was initially developed, although not used, by the United States during World War I. It was believed to have much greater toxicity than mustard gas, with some animal data suggesting that as little as one-third teaspoon on the skin would result in human death (Vilensky 2005). During the period between World Wars I and II, all major countries developed lewisite production facilities and, as World War II loomed, both Great Britain and the U.S. initiated research projects designed to develop an antidote to lewisite. On July 21, 1940, an Oxford University group of chemists reported the successful development of British anti-Lewisite (BAL) (Ord 2000). On first arrival in the United States in 1941, a series of studies was initiated to determine BAL's biochemistry, pharmacology, experimental therapeutics, and clinical applications (Waters and Stock 1945). Improvements in synthesis resulted in the development of effective therapeutic ointments and solutions. BAL was produced during World War II by DuPont. Plans for the possible production of 200,000 pounds per year were developed (Waters and Stock 1945). During and after the war, nonmilitary uses for the heavy metal chelating action of BAL became apparent. Eagle and Magnuson found that 48 patients with severe or mild symptoms of arsenical encephalopathy were effectively treated with BAL (Eagle and Magnuson 1946). By 1947, 32 articles had been published or were in press on the therapeutic value of BAL (Ord 2000). BAL was the drug of choice for treatment of intoxication with arsenic, antimony, mercury, and gold. It was also considered effective in cases of intoxication with bismuth, copper, and nickel (Deichmann and Gerarde 1964).

In 1949, Porter found a 7-fold increase in copper excretion in 2 patients with Wilson disease and some decrease in neurologic signs after treatment with BAL (Porter 1949). In 1951, Cummings at the National Hospital, Queen Square, and Denny-Brown and Porter at Boston City Hospital conducted studies on the long-term effects of BAL in 4 and 5, respectively, patients with Wilson disease. The effects were definitive and dramatic; the patients exhibited great improvement in accordance with marked increases in urinary copper excretion (Cummings 1951; Denny-Brown and Porter 1951). BAL's use as the primary treatment for Wilson disease was short-lived because Walshe, in 1956, showed the value of the less toxic chelating agent, penicillamine (Walshe 2009). Other agents have been developed since (Brewer 1999). Nevertheless, BAL may still have some therapeutic value in patients who do not respond well to more modern agents (Scheinberg and Sternlieb 1984). It has been postulated that, because BAL is nonpolar, it may accelerate the removal of copper from within the brain compared to more modern agents (Scheimberg and Sternlieb 1984; Walshe 1999).

BAL is not generally recommended for use today because more efficient and safer chelators for oral or parenteral administration have been developed (Andersen 1999; Blanusa et al 2005; Archer 2008). In the United States it is marketed by Akorn as BAL in Oil® in 3 mL 100 mg/mL single-use ampoules (the solute is peanut oil).

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